Navigating self-expandable metallic stent placement in inoperable esophageal malignancies: A landmark-based technique using the vertebral column and diaphragm

Figure 1  The Strengthening the Reporting of Observational studies in Epidemiology flow diagram illustrating the selection of study participants, including eligibility assessment, exclusions with reasons, and the final cohort included in the analysis.

Figure 2 Representative images of self-expandable metallic stent placement utilizing the vertebral column and diaphragm as landmarks in a 62-year-old male with a history of dysphagia and weight loss diagnosed with squamous cell carcinoma with distant metastasis. A: Endoscopy revealed a circumferential and friable growth 35 cm from the incisors. The gastroesophageal junction was involved at 39 cm, extending to 1 cm of the cardia. An ultrathin gastroscope was passed with resistance. A guidewire was placed into the stomach under endoscopic guidance; B: Fluoroscopic imaging showed the ultrathin gastroscope at the proximal extent of the tumor. The blue arrow indicates the corresponding vertebra in line with the proximal extent of the tumor (i.e., two vertebrae above the diaphragm); C: Fluoroscopic imaging showed the ultrathin gastroscope at the distal extent of the tumor. The blue arrow indicates the corresponding vertebra in line with the distal extent of the tumor just above the diaphragm; D: Fluoroscopic imaging after self-expandable metallic stent (22 mm × 100 mm) placement under the guidance of vertebral markings, after adding one vertebra above and one vertebra below the proximal and distal extent of the tumor. The blue arrows indicate the corresponding vertebrae in line with the proximal and distal ends of the stent (i.e., four vertebrae in total); E: Endoscopic view after self-expandable metallic stent placement showed the proximal end of the stent covering 2 cm of the normal mucosa proximally. SEMS: Self-expandable metallic stent.

Figure 3 Representative images of self-expandable metallic stent placement utilizing the vertebral column and diaphragm as landmarks in a 70-year-old female with a history of dysphagia, cough, and weight loss diagnosed with squamous cell carcinoma and locally advanced disease with tracheoesophageal fistula. A: Endoscopy showed a circumferential growth starting at 25 cm from the incisors and extending up to 36 cm. The gastroesophageal junction was measured at 40 cm. A guidewire was placed into the stomach under endoscopic guidance; B: The endoscopic view showed esophageal growth on the left side and the tracheoesophageal fistula at 27 cm from the incisors on the right side; C: Fluoroscopic imaging showed the ultrathin gastroscope at the distal extent of the tumor with the guidewire in place. The blue arrow indicates the corresponding vertebra in line with the distal extent of the tumor (i.e., one vertebra above the diaphragm); D: Fluoroscopic imaging showed the ultrathin gastroscope at the proximal extent of the tumor. The blue arrow indicates the corresponding vertebra in line with the proximal extent of the tumor (i.e., six vertebrae above the diaphragm). The self-expandable metallic stent was placed under the guidance of vertebral markings, after adding one vertebra above and one vertebra below the proximal and distal extent of the tumor; E: Endoscopy after self-expandable metallic stent placement showed the proximal end of the stent effectively bridging the tumor and covering 2 cm of the normal mucosa proximally. TEF: Tracheoesophageal fistula.